Every finding on record at Citadel Care Center-Wilmette

Based on observation, interview, and record review, the facility failed to ensure that the residents' controlled medications were properly received and documented on according to facility policy by failing to: 1. Maintain documentation of receiving controlled medications, upon receipt of medication into the facility and maintaining administration information for controlled medications; this deficient practice affected two (R1 and R8) of two residents. This deficient practice affected two (R1 and R8) of two residents reviewed for controlled medication management in the sample of 60 and has the potential to affect all residents prescribed controlled medications in the facility.Findings:R1 is an [AGE] year-old resident, on hospice care, with diagnoses of, but not limited to hemiplegia, unspecified, affecting left, non-dominant side, cerebral palsy, unspecified, and unspecified osteoarthritis, unspecified site.R8 is a [AGE] year-old resident, on hospice care, with diagnoses of, but not limited to other cervical disc degeneration, unspecified cervical region, sciatica, unspecified side, and peripheral vascular disease, unspecified.On 04/06/2026 at 10:50 AM, this surveyor encountered V4 (Registered Nurse) at the second-floor nursing station. V4 has worked as a nurse as needed (PRN/pro re nata) for five years and states they usually work a couple of days per week.At 10:55 AM, V4 accompanied this surveyor to the second-floor medication cart for investigation. V4 stated that this is the sole medication cart for this unit. During the controlled medication observation, it was observed that there were three liquid controlled medications (two located in the controlled box within the cart and one located within the controlled box within the storage refrigerator) that did not have a controlled medication requisition logs present on the unit. V4 was observed looking through the controlled medication logs on the medication cart and went through documents behind the nurse's station to see if it had been misplaced. V4 stated, we don't have it, but we should. This surveyor observed the medication requisition logbook with double signatures (two nurses) every time a count was done despite these medications being excluded from the logbook.The bottle located in the refrigerator belonged to R1 and was labelled Morphine Sulfate Concentrate Oral Solution 100 mg/5 ml and had 6 ml remaining in the bottle, one bottle located in the medication storage refrigerator belonged to R1 and was labelled Morphine Sulfate Concentrate Oral Solution 100 mg/5 ml and had 15 ml remaining, and the second bottle located in the medication storage refrigerator belonged to R8 and was labelled Morphine Sulfate Concentrate Oral Solution 100 mg/5 ml and had 4 ml remaining. Bottles were all stored within their own bag, were dry and did not appear to be leaking. V4 began creating medication requisition logs for each of these medications in front of this surveyor.At 12:30 PM, this surveyor requested copies of the medication requisition logs that V4 was creating earlier in the day, from V4; V4 stated that they began creating the forms and while filling them out, V2 requested the forms to review, in the nursing department. V4 called V2 and requested the forms for this surveyor and brought them once received. The forms were as follows (only two forms for Morphine were given to this surveyor):R8 - Morphine Sulfate Oral Solution 100 mg/5 mlR1 - Morphine Sulfate (no concentration listed)On 04/07/2026 at 8:40 AM, this surveyor spoke to V2 regarding controlled medication policy and protocols in the facility. V2 stated that residents who are not on hospice care receive controlled medications from their in-house contracted pharmacy; V2 states that these controlled medications come with medication requisition logs. V2 stated that hospice medications come from the hospice contracted pharmacy and states these controlled medications do not come with medication requisition logs. V2 states that the medications are taken in by a nurse and placed in the medication storage refrigerators on the correlating residents' floor; V2 states that a medication requisition log will only be created once medication is taken out for use. This surveyor advised V2 that controlled medications were found in a medication cart and medication storage room and did not have medication requisition logs in the controlled medication logbook on that cart. V2 stated, that's a problem.On 04/07/2026 at 11:30 AM, V2 brought the four controlled medication bottles to the surveyors on site. At this time, the bottles remained in their individual bags but all were wet, sticky, had a rubber/plastic top that was not present the day prior, and medication was leaking out from the tops; this is not the condition these medications were found in on the second floor medication cart or medication storage room while investigating the morning prior with V4 present. V2 stated that the bottles that are not full, must have been leaking because they were not penetrated on the top.At 11:40 AM, record review of the electronic medication administration record revealed that these three Morphine prescriptions (even the ones with medication missing from the bottles) have not been documented as given since the most recent order dates. The most recent physician order for R8's two Morphine prescriptions is 11/05/2026 (only one prescription bottle for Morphine was located on the unit) and the physician order for R1's two Morphine prescriptions was dated 06/28/2025.On 04/08/2026 at 4:30 PM, this surveyor spoke to V16 (hospice contracted pharmacy technician) at the contracted pharmacy of the facility-contracted hospice company. V16 stated that all controlled medications that are sent to a facility, whether for a hospice resident or non-hospice resident, are sent with a medication requisition log to properly track medication administration.On 04/08/2026 at 4:33 PM, this surveyor spoke to a receptionist at the facility-contracted hospice company who verified that the pharmacy used for their hospice residents is the pharmacy that V2 previously mentioned.Facility Policy:04/06/2026 at 11:00 AMThe Controlled Substances facility policy was received from V2 (Director of Nursing).Facility Policy named Controlled Substances, dated December 2025 states in part but not limited to:3. Controlled substances must be counted upon delivery. Both individuals must sign the designated controlled substance record. For controlled substances supplied by palliative or hospice, the nurse will acknowledge delivery, and inventory/accounting will begin upon first use.4. If the count is correct, an individual resident - controlled substance record must be made for each resident who will be receiving a controlled substance. Do not enter more than one (1) prescription per page. This record must contain:a. Name of the residentb. Name and strength of medicationc. Quantity receivedd. Number on [NAME]. Name of physicianf. Prescription numberg. Name of issuing pharmacyh. Date and time receivedi. Time of administrationj. Method of administrationk. Signature of person receiving medicationl. Signature of nurse administering medication9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.

Based on interview and record review, the facility failed to follow their policy related to psychotropic medications and ensure one resident (R49) was free from unnecessary psychotropic medications. Findings Include: R49 is an [AGE] year-old female who admitted to the facility on [DATE] and continues to reside in the facility. R49 has multiple diagnoses including but not limited to the following: difficulty in walking, lack of coordination, and osteoarthritis. Per physician orders resident is receiving Quetiapine Fumarate Oral Tablet 25 mg - Give 0.5 tablet by mouth at bedtime for sleep/anxiety. On 2/19/2025 at 12:25PM, R49 was noted to be calm and alert and oriented with no behaviors. On 2/19/2025 at 1:30PM, V2 (Director of Nursing) said, R49 came to the facility already receiving an antipsychotic medication. The attending physician is to decide whether to refer them to receive psychiatric care. She was seen on 2/19/2025 and there was no recommendation for psychiatric evaluation. Per progress note, there was no concerns identified with R49's mental health. R49 does not have any serious mental illness diagnoses. On 2/20/2025 at 12:15PM, V19 (Nurse Practitioner) said, I am unsure as to why R49 is on this medication or when she started taking this. When I have seen R49, she doesn't display any issues or behaviors. I have not witnessed her display any sort of anxiety or sleeplessness out of the ordinary. Review of records for R49 does not have a diagnosis of a serious mental illness, insomnia, or anxiety. No behavior documentation or indication for use of medication was given to this surveyor. Facility policy titled Psychotropic Medication Use with Revision Date of December 2024 states in part but not limited to the following: Policy Interpretation and Implementation: 1. Residents will only receive psychotropic/antipsychotic medications when necessary to treat specific conditions which they are indicated and effective. 4. The attending physician and facility staff will identify acute psychiatric episodes and will differentiate them from enduring psychiatric conditions. 5. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. The interdisciplinary team will: Re-evaluate the use of the antipsychotic medications at the time of admission and/or within two weeks to consider whether the medication can be reduced, tapered, or discontinued. Based on assessing the resident's symptoms and overall situation, the physician will determine whether to continue, adjust, or stop existing antipsychotic medication. 7. Antipsychotic medications shall generally be used only for the following conditions/diagnoses documented in the record: Schizophrenia, Schizo-affective disorder, Schizophreniform disorder, Delusional disorder, Mood disorders, psychosis, medical illnesses with psychotic symptoms, Tourette's Disorder, Huntington Disease, Hiccups, nausea and vomiting associated with cancer or chemotherapy. 11. Antipsychotic medications will not be used if the only symptoms are one or more of the following: restlessness, impaired memory, mild anxiety, insomnia, sadness, nervousness, etc.

Based on observation, interview, and record review, the facility failed to safely transfer a resident (R1) with a mechanical lift. This applies to 1 of 3 residents reviewed for safety & supervision in the sample of 4. The findings include: R1's electronic face sheet showed R1 has diagnoses including but not limited to urinary tract infection, morbid obesity, acute pulmonary edema, and heart failure. R1's facility assessment dated [DATE] showed R1 has no cognitive impairment and is dependent on staff for all transfers. R1's weight documented 12/6/23 showed R1 weighs 363.4lbs. R1's care plan dated 10/26/23 showed, The resident has an activities of daily living (ADL) self-care performance deficit related to activity intolerance, impaired balance, limited mobility, musculoskeletal impairment, and pain .The resident requires assistance from 2-3 staff to move between surfaces with a mechanical lift. On 12/9/23 at 10:30AM, R1 stated, The staff use a (mechanical lift) to get me in and out of bed. They are never careful with me, and I don't feel safe. They are always banging my legs into things, and I can't even tell you how many times they have almost hit my head with the bar that goes over top of me. I don't think the staff here are equipped to handle someone my size. On 12/9/23 at 11:36AM, V4, V5, and V6 (Certified Nursing Assistants/CNA) transferred R1 from her bed to her wheelchair. During the mechanical lift transfer, the mechanical lift grab bar was parallel with R1's body causing the sling to be attached in an incorrect manner. (Mechanical lift grab bar is to be placed perpendicular with the resident's body to ensure full body sling coverage). R1's head had to be tilted to the left side during the transfer to avoid contact with the mechanical lift grab bar. Throughout the transfer, R1's body was swaying in the lift while V6 rolled over 2 different cords with the lift, causing R1's legs to swing into the base of the lift. R1 instructed V4, V5, and V6 several times during the transfer on how to maintain her body in alignment to avoid her limbs and head hitting parts of the lift. On 12/9/23 at 2:01PM, V4, V5, and V6 transferred R1 from her wheelchair to her bed in the same manner with the mechanical lift grab bar parallel to R1's body. V6 stated that is how he has always used the mechanical lift and it works just fine. On 12/9/23 at 2:31PM, V9 (Physical Therapist) stated, I'm not entirely sure how the (mechanical lift) transfers are supposed to work for (R1). I haven't actually seen the staff do them and I didn't do any training with them on the lift with her. On 12/9/23 at 3:20PM, V3 (Director of Nursing) stated, I can't confirm how the grab bar is supposed to be positioned with the (mechanical lift). I'm not sure what (R1's) transfer status is, therapy handles all of that. On 12/9/23 at 4:22PM, V3 stated, We can't transfer (R1) the correct way because she said it hurts her back. It is documented that we spoke with her about this, and she confirmed she understood the risks with not using the lift properly. (The facility was unable to provide documentation regarding this conversation with R1 and R1 declined knowledge of this conversation). The facility's policy titled, Using a mechanical lifting machine dated 07/2019 showed, The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions .12. Attach sling straps to sling bar, according to manufacturer's instructions. A. make sure the sling is securely attached to the clips and that is properly balanced. B. check to make sure the resident's head, neck and back are supported . The undated mechanical lift owner's manual provided by the facility showed, Move the lift slowly towards the user and position the spreader (grab) bar over the user's patient's chest.

Based on observation, interview, and record review, the facility failed to perform incontinence care and provide catheter care in a manner to prevent urinary tract infections for 1 resident. The facility also failed to position a resident's urinary catheter bag off the floor for 1 resident. These failures apply to 2 of 3 residents (R1, R2) reviewed for incontinence care in the sample of 4. The findings include: 1) R1's electronic face sheet showed R1 has diagnoses including but not limited to urinary tract infection, morbid obesity, acute pulmonary edema, and heart failure. R1's facility assessment dated [DATE] showed R1 has no cognitive impairment and is occasionally incontinent of bladder. R1's care plan dated 10/26/23 showed, The resident is at risk for incontinence related to activity intolerance, has current bowel incontinence, current urinary incontinence, impaired mobility, physical limitations, and diagnosis of overactive bladder .The resident uses disposable briefs. Change as needed. Check routinely, upon request, as needed for incontinence. Wash, rinse, and dry the perineum, and apply a barrier cream. On 12/9/23 at 10:30AM, R1 stated, I was in the hospital at the beginning of November for a urinary tract infection. They told me it was a complicated infection and I had to get intravenous antibiotics. They don't change me enough here and when they do, they don't clean me well. On 12/9/23 at 11:36AM, V4, V5, and V6 (Certified Nursing Assistants) provided incontinence care for R1. V6 removed R1's heavy, urine soaked and odorous incontinence brief. V6 cleansed both sides of R1's groin with the same side of the wipe and then pushed the wipe down into R1's vaginal area. V6 performed this action twice in a row while wiping from R1's groin down into her vaginal area. V6 then cleansed R1's vagina by wiping 4 times down the front of R1's vagina with the same side of the wipe. V6 stated that is how he provides incontinence care, and no one has ever told him differently. V6 stated there is nothing incorrect with the way he provides incontinence care. On 12/9/23 at 3:20PM, V3 (Director of Nursing) stated, When staff are providing incontinence care for a female resident, they should be cleansing the groin and vaginal area with different wipes, not wiping from the groin down into the vaginal area. If staff clean a resident's groin and push it into the vaginal area that could introduce bacteria into the vagina and puts the resident at risk for a urinary tract infection. The facility's policy titled, Perineal Care dated 02/2018 showed, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition .For a female resident: b. wash perineal area, wiping from front to back. 1) Separate the labia and wash area downward from front to back. 2) Continue to wash the perineum moving from inside outward towards the thighs . 2) R2's electronic face sheet printed on 12/9/23 showed R2 has diagnoses including but not limited to multiple sclerosis, need for assistance with personal cares, and neuromuscular dysfunction of bladder. R2's facility assessment dated [DATE] showed R2 has no cognitive impairment and is dependent on staff for personal hygiene. R2's care plan dated 11/11/23 showed, The resident has a Suprapubic Catheter: (Neurogenic bladder. Foley catheter) and chronic obstructive pyelonephritis. On 12/9/23 at 1:10PM, R2's urinary catheter bag was laying on R2's floor, in direct contact with the floor. R2 stated, Right before I was admitted here, I was in the hospital for a urinary tract infection, and I ended up with sepsis. I was very ill and in the hospital for quite a while, so they kept the catheter in me to see if it helps with my infections. On 12/9/23 at 1:36PM, V7 and V8 (Certified Nursing Assistants) provided urinary catheter care for R2. V8 cleansed each side of R2's groin with the same side of the wipe and then pressed the wipe down into R2's vaginal area. V8 did not clean R2's vaginal area or catheter tubing. R2's vaginal area had several chunks of a white substance stuck on her vagina. V7 stated R2's urinary catheter drainage bag should not be on the floor due to infection control concerns. On 12/9/23 at 3:20PM, V3 (Director of Nursing) stated, Catheter bags should always be placed in a dignity bag and should never be lying on the floor due to infection control. When performing catheter and perineal care for a resident with a catheter, the staff should be cleansing the vagina and wiping down the catheter tubing to prevent infections. The facility's policy titled, Perineal Care dated 02/2018 showed, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition .for a female resident: 1) if the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.

Based on observation, interview and record review, the facility failed to monitor and maintain the resident's personal refrigerator temperature for two of four residents (R12, R52) reviewed for food safety in a sample of 15. Findings include: R12's order summary report dated 4/13/2023 indicated admitted [DATE] and diagnosis of but not limited to pure hypercholesterolemia. R52's order summary report dated 4/13/2023 indicated admitted [DATE] and diagnosis of but not limited to depression. On 04/11/2023 at 10:11 AM during observation with V3 (Assistant Director of Nursing), R12's personal refrigerator temperature had no April 2023 log observed by the refrigerator. The refrigerator was observed with multiple food items inside. V3 stated that resident's refrigerator temperature should be checked daily by maintenance. On 04/11/2023 at 10:41 AM during observation with V6 (Registered Nurse), R52's personal refrigerator temperature log for April 2023 was noted blank and food items were observed inside the refrigerator. V6 said that resident's refrigerator temperature should be checked daily by the Certified Nursing Assistants (CNAs). On 04/13/2023 at 2:36PM, V15 (Maintenance Director) said that resident's refrigerator should be checked by the managers assigned to rooms daily and if they are not available, the CNAs or unit staff are expected to check it. He also mentioned that he checks it each week or throughout the week to see if it is being monitored. Facility Policy: Title: Food [NAME] in By Family or Visitors - Personal Refrigerators Procedure: Personal refrigerator temperatures should be maintained at 41 degrees Fahrenheit or below.

Based on observation, interview, and record review the facility failed to ensure the indwelling urinary bag was placed in a dignity bag for 1 of 2 residents (R112) reviewed for indwelling urinary catheter in a sample of 15. Findings include: On 4/11/2023 at 10:45am R112 was observed in bed with his urinary collection bag facing the door without a privacy bag covering. On 4/11/2023 at 10:46am V10(Certified Nursing Assistant/CNA) said the urinary collection bag should have a privacy bag always covering it. On 4/13/2023 at 12:46pm V3(Assistant Director of Nursing/ADON) said I expect all urinary collection bags to have a privacy bag always covering it. An Order Summary Report dated 4/1/2023-4/30/2023 indicates R112 has a diagnosis of Benign Prostatic Hyperplasia without lower urinary tract symptoms. A care plan that indicates R112 has a focus of Neurogenic bladder with interventions that the Catheter must have a dignity bag covering it. Facility Policy: Reviewed December 2018 Quality of Life-Dignity Policy Statement Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Policy interpretation and Implementation 11. Demeaning practices and standards of care that compromise dignity is prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep the urinary catheter bags covered.

Based on observation, interview, and record review, the facility failed to implement their fall intervention for one resident (R22) out of nine residents reviewed for fall in the sample of 15. Finding includes: R22 was admitted on [DATE] with diagnosis not limited to unspecified dementia, psychotic disturbance, and anxiety disorder. Nursing: Quarterly Morse Fall Scale dated 3/16/23 documents: R22 Score = 60 and category: High Risk for Falling. R22 had a fall on 12/12/2022. R22 Care plan fall intervention on 12/12/2022 documents: floor mattress next to bed when R22 is in bed. On 4/11/22 at 10:30 am, R22 was observed sleeping in bed and no floor mattress was next to her bed. On 4/11/2023 at 4:00 pm, R22 was observed again sleeping in bed and no floor mattress was next to her bed. On 4/12/2023 at 12:07, R22 was observed for sacral wound dressing change by V9 (Wound Care Nurse) and no floor mattress was next to her bed. On 4/12/2023 at 3:38 pm, R22 was observed in her bed with V4 (Care Plan Coordinator/MDS) and no floor mattress was next to her bed. V4 said that R22 should have a floor mattress next to her bed. Facility: Falls and Fall Risk, Managing Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on observation, interview, and record review the facility failed to ensure that the urinary drainage bag was placed below the bladder for 1 of 2 residents (R112) reviewed for urinary catheter in a sample of 15. Findings include: On 4/11/2023 at 10:45am R112 was observed in bed with his urinary drainage bag positioned above his waist. On 4/11/2023 at 10:46am V10(Certified Nursing Assistant/CNA) said the urinary collection bag should place below his waist. On 4/14/2023 at 12:50pm V3(Assistant Director of Nursing/ADON) said I expect all urinary drainage bags to be positioned below the waist to prevent a urinary tract infection. An Order Summary Report dated 4/1/2023-4/30/2023 indicates a diagnosis of Benign Prostatic Hyperplasia without lower urinary tract symptoms and Neuromuscular dysfunction of bladder, unspecified. A care plan with a focus that indicated R112 has an indwelling catheter related to neurogenic bladder. An intervention that indicates R112's indwelling catheter and tubing below the bladder level and away from the entrance room door. Reviewed September 2019 Catheter Care, Urinary Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Preparation: Maintaining Unobstructed Urine Flow 3. The urinary drainage bag must be always held or positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based in interview and record review, the facility failed to develop an effective fall intervention to include monitoring and supervision for a resident assessed to be high risk for falls, has history of falls, has poor safety awareness, and has impulsive behaviors. This affected 1 of 3 residents (R1) reviewed for falls and fall prevention. This failure resulted in R1 getting up unsupervised, falling to the floor which resulted in a forehead laceration which required sutures. Findings include: On 3-31-23 at 10:05 AM, R1 is primarily Spanish speaking and translator was needed. Surveyor attempted to carry conversation with R1 via translator and R1 was confused and unable to carry a meaningful conversation. On 3-31-23 at 11:23 AM, V2 (Director of Nurses/DON) said R1 is alert and able to make her needs known. V2 said R1 is confused and nonsensical per translator. V2 said R1 is unable to carry pertinent and meaningful conversation. V2 said R1 has poor safety awareness due to confusion, impulsive behaviors, and inability for redirection at times. V2 said R1 has moments of agitation in which she requires time to calm down and de-escalate. V2 said R1 has impulsive behaviors of changing her mind and will try to get up from chair or bed without telling staff. V2 said R1 does not use the call light despite encouragement from staff. V2 said R1 has dementia and encephalopathy. V2 said R1 is a high fall risk, and she thinks R1 has a history of falls. V2 said R1 had measures in place prior to recent fall. R1 was in a room close to the nurse station. On 3-31-23 10:22 AM, V3 (Licensed Practical Nurse/LPN) said R1 is Spanish speaking and requires translator. V3 said R1 is alert, oriented x 1-2 with a translator, and confused at times. V3 said R1 is impulsive and will try to get up from bed without calling for assistance. V3 said R1 does not use the call light despite staff redirection. V3 said R1 is a high fall risk due to impulsive behavior and confusion. V3 said R1 is difficult to redirect due to confusion. V3 said R1 has history of falls. On 3-31-23 at 10:43 AM, V4 (Certified Nurse Assistant/CNA) said R1 is Spanish speaking and can make her needs known with a translator. V4 said R1 is confused at times and will attempt to get up from bed and wheelchair without calling for assistance. V4 said the staff ensure call light is in reach however R1 does not use the call light. V4 said R1 is impulsive and will try to get up by herself. V4 said R1 has poor safety awareness due to confusion, impulsive behavior, and non-compliant with using call lights. On 3-31-21 at 12:40 PM, V5 (LPN) said R1 is alert, confused (per her baseline), and is able to make her needs known through a translator. V5 said R1 gives simple one-word responses instead of carrying a conversation and R1 has dementia. V5 said R1 has poor safety awareness because she is impulsive and does what she wants to do without calling for assistance. V5 said R1 is a high fall risk because she thinks she can still do things and has an unsteady gate. V5 said R1 tries to get up by herself all the time thus the staff has to provide frequent rounding as much as possible. V5 said R1 must be kept in public eye for observation and supervision. V5 said he is unsure of R1 having a history of falls. R1 can sometimes be redirected and still must be frequently rounded on. V5 said R1 is placed in doorway to room closest to the nurses' station due to fall risk and isolation precautions and Everyone walking by can see R1 in her doorway. R1 was on isolation and could not be out of her room due to isolation precautions. V5 said he saw R1 get up from wheelchair in the doorway, V5 got up and was unable to prevent R1 from falling when R1 got up by herself. V5 said he noted laceration on R1's forehead with moderate amount of blood. No other visible injuries noted. V5 said he cleansed the wound and provided pressure dressing, called 911, MD (medical doctor), and the family. Family would meet R1 at the hospital. V5 said he was not on duty when R1 came back. R1 came back with stitches to the forehead. On 3-31-23 at 10:56 AM, V6 (CNA) said R1 is alert, confused most of the time, and can use sign language to make her needs known. V6 said R1 has nonsensical conversations. V6 said R1 has poor safety awareness and will try to get up without asking for staff assistance. V6 said R1 high fall risk due to confusion. V6 said she is unaware of previous fall history for R1. V6 said she would check on all residents every 10 minutes. Face Sheet documents: Diagnosis Information: Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. MDS (ARD 2-17-23) documents: Should Brief Interview for Mental Status be conducted? 0. No (resident is rarely/never understood). Transfer (Self-Performance): 3. Extensive assistance- resident involved in activity, staff provides weight-bearing support. Transfer (Support): 2. One-person physical assist. Balance During Transitions and Walking: Moving from seated to standing position: 2. Not steady, only able to stabilize with staff assistance. Surface-to-surface: 2. Not steady, only able to stabilize with staff assistance. Risk For Fall Care Plan documents falls on 12-14-20, 1-1-21, 2-10-21, 9-20-21, 6-27-22, 7-6-22, and 8-20-22, 2-18-23, and 2-21-23. Initial Reportable dated 2-21-23 documents: At 12:12 PM, alert resident lost her balance after standing from the wheelchair and fell to the floor. Observed with a moderate amount of bleeding from her forehead with skin tear. No other apparent injury. The resident denies loss of consciousness, difficulty breathing she was yelling and talking out loud in Spanish. 11 emergency services was called, cold compress applied to her forehead. Neuro-checks initiated and within normal limits. No change to baseline. Staff remained with resident till the emergency crews arrived. She was transported on the stretcher to local hospital ED for further evaluation and treatment. She was alert and talking at the time of transfer, no apparent distress. NP (Nurse Practitioner) to primary MD (Medical Doctor), DON, and family was notified of fall and transfer to hospital. The resident returned from hospital at 6:00 PM with sutures to forehead and to remove sutures in 7-10 days. PT/OT (Physical Therapy/Occupational Therapy) to eval and treat. Final report to follow. Final Reportable dated 2-28-23 documents: At 12:12 PM, alert resident lost her balance after standing from the wheelchair and fell to the floor. Observed with a moderate amount of bleeding from her forehead with skin tear. No other apparent injury. The resident denies loss of consciousness, difficulty breathing she was yelling and talking out loud in Spanish. (11 emergency services was called, cold compress applied to her forehead. Neuro-checks initiated and within normal limits. No change to baseline. Staff remained with resident till the emergency crews arrived. She was transported on the stretcher to local hospital ED for further evaluation and treatment. She was alert and talking at the time of transfer, no apparent distress. NP to primary MD, DON, and family was notified of fall and transfer to hospital. The resident returned from hospital at 6:00 PM with sutures to forehead and to remove sutures in 7-10 days. PT/OT to eval and treat. Final report to follow. 2-28-23- The resident is stable and receiving PT/OT. The sutures will be removed 3-3-23. Care plan reviewed and updated. Incident Audit Report dated 2-21-23 documents: Prior to the incident, resident was taken to the toilet by the CNA, and she was sitting in her wheelchair by her room doorway closer to the nursing station. Just about 10 minutes later at 12:12 PM, this nurse observed the resident standing up from her wheelchair, rushed to her and was unable to redirect in time. Observed the resident falling face down to the floor in the hallway. The resident leaned towards left side laying on the ground. Observed with a moderate amount of bleeding from her forehead with skin tear. Hospital Record dated 2-21-23 documents: 91 YO female presents after fall. History obtained from patient's nurse at facility, who states earlier this morning she was witnessed to stand up from her wheelchair and fall forward before staff could come to assist her, is not able to ambulation her own at baseline. She fell forward hitting her head but was not witnessed to lose consciousness, was screaming, and yelling immediately afterward c/o of pain to left shoulder and hand. Patient states she has pain there but denies headache. Rest of history limited as patient is Ao (alert and orientated) x1 at baseline due to dementia. Progress Note dated 2-21-23 documents: Note Text: Pt. returned from (local) Hospital E.R. with Dx. of Laceration to her Forehead and had 6 stitches covered with gauze dressing. No c/o headache or pain upon return. On 4-4-23 at 9:10 AM, Administrator, Assistant Director of Nurses, Maintenance Director, and the surveyor were able to measure the distance from V5's (Licensed Practical Nurse) seat at the nurses' station to R1's doorway of previous room. The distance was approximately 28 feet. Falls and Fall Risk, Managing Policy (revised March 2018) documents: Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on observation, interview and record review, the facility failed to place appropriate warning notification regarding transmission-based precautions on the door of residents that are under isolation and failed to provide PPE's (Personal Protective Equipment) for use in an isolation room for one (R2) out of 3 residents reviewed for transmission-based precautions. Findings include: R2 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS (Minimum Data Set) dated 04/06/2022 shows R2 with a BIMS (Brief Interview of Mental Status) score of 11 indicating moderately impaired cognition. On 07/18/2022 at 10:40 AM During entrance conference, V1 (Administrator) indicated that there is one resident in the facility (R2) on isolation precautions for [CONDITION(S)] in the blood and that there are 26 total residents occupying the unit. On 07/18/22 at 11:21 AM Surveyor approached R2's room. Upon observation, there was no isolation precaution sign posted, nor a personal protective equipment cart outside of the room for staff to use prior to entering R2's room and to indicate that R2 is on current isolation precautions. On 07/18/2022 at 11:25 AM Surveyor asked V4 (Certified Nursing Assistant) about R2's isolation precaution status, V4 stated He (R2) is not on isolation. On 07/18/2022 at 11:28 AM Surveyor asked V3 (LPN/Licensed Practical Nurse) about R2's isolation precaution status, V3 said, I think R2 is on isolation precautions. Surveyor clarified that V1 (administrator) indicated that R2 has [CONDITION(S)] in the blood. Surveyor pointed out that there is no isolation sign nor PPE cart by R2's room, V3 stated, Yes, he has [CONDITION(S)] in the blood, and he is on isolation precautions, but you don't have to wear PPE (Personal Protective Equipment) because it's contained in his blood. Surveyor questioned whether V3 is certain that there is no need to wear PPE upon entering R2's room; V3 walked away to verify isolation precautions for R2. On 07/18/2022 at 11:32 AM, surveyor observed V4 (CNA) putting up contact isolation precaution sign on R2's door and setting up PPE (Personal Protective Equipment) cart. On 07/18/2022 at 11:40 AM Surveyor verified Point of Service plan for R2 dated 07/12/2022 10:26 AM which reads in part, COVID Isolation-Precautionary admit/readmit: Contact/droplet x14 days. On 07/18/22 at 11:55 AM Surveyor asked V2 (Director of Nursing) to explain discrepancy in R2's isolation precaution order and lack of isolation precaution sign and PPE (Personal Protective Equipment) set up, V2 said, R2 has an active order for contact isolation precaution for [CONDITION(S)] in the blood. Surveyor questioned why R2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 is fully vaccinated and does not need to be on contact/droplet isolation precautions, he is only on contact isolation precautions for [CONDITION(S)] in the blood On 07/18/2022 at 01:40PM Surveyor verified Point of Service plan for R2 dated 07/18/2022 11:42 AM which reads in part, Contact Isolation: [CONDITION(S)] BLOOD. Infection Control Policy and Procedure Manual Citadel Healthcare revised October 2018 reads in part, Transmission-based precautions are additional measures that protect staff, visitors, and other residents from becoming infected. When resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. The signage informs staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room.

Based on interview and record review the facility failed to ensure that staff treat residents in a dignified manner. This applies to 3 of 4 residents (R1, R2, R3) reviewed for dignity in a sample of 4. The findings include: 1. On 3/25/22 at 10:30 AM R1 stated, (V3 CNA) was rough with changing me. She came in at night by herself and tried to change me. She thinks she is the manager or something. She took care of me many times and I heard she was moved to 3rd floor. I've asked many times to have her removed from my care. She would also keep the call light away from me. She was very hard to understand. Oh yes, I was afraid of her. I was afraid she was going to hurt me. I complained many times, and nothing ever gets done. Surveyor asked R1 if V3 ever physically hit R1 or was she just rough when turning R1 back and forth in the bed? R1 stated, She was just rough. R1's Minimum Data Set assessment dated [DATE] shows that R1 has no cognitive impairment. R1's Incident Report dated 2/25/22 states, [AGE] year-old, alert and confused resident verbalized that (R1) felt afraid because a staff member had made physical contact on (R1's) legs and body. 2 RNs performed full body assessments, no redness or discoloration observed. Patient denies pain . NP (Nurse Practitioner) came and assessed resident no signs of abuse or neglect .Staff involved was suspended pending investigation . Abuse was not substantiated. V3's 2nd Written Warning on the Employee Discipline Form dated 2/25/22 states, Staff was reported by family. Reporting that patient (R1) verbalized that staff was mean and that she was hitting patient. Staff was suspended pending investigation. Called staff over the phone. She denied allegations. The Violations checked on this form are Conduct and Performance. On 3/25/22 at 1:00 PM V2 (Director of Nursing) stated, I had to discipline (V3). I suspended her then terminated her for misconduct. She was not performing good customer service. It was an accumulation of things, being insubordinate and not listening to the nurses. I have my own file from Monday when I terminated her. She was already suspended from last Thursday. (V3) became irate and hung up the phone. With (R1) it was a customer service issue. So, we offered R1 more choices of who cares for (R10. (V3) needed education on how to treat the residents. I pulled her away from (R1) - just switched the assignments on the floor. 2. On 3/25/22 at 10:45 AM R2 was in R2's wheelchair in the dining room for the activity. R2 was not participating and had R2's head down on the table. R2 agreed to go to R2's room to talk to the surveyor. Surveyor questioned resident about incident reported by R2's family member on 3/17/22 regarding staff yelling at R2. R2 was prompted multiple times but R2 stated R2 doesn't really remember anything. R2 stated R2 is not afraid of staff now but seems very hesitant to talk to surveyor. R2 apologized for not knowing what to say. R2's Primary language is Spanish, and surveyor offered to find a Spanish speaking interpreter but R2 declined. R2's Minimum Data Set assessment dated [DATE] shows that R2 has moderate cognitive impairment. R2's Incident Report dated 3/17/22 states, [AGE] year-old, alert, and oriented resident. Family member verbalized that resident feels uncomfortable because a staff member raised her voice at the resident and awoke (R2) early for a shower . Resident assessed no signs and symptoms of abuse or neglect . No findings concluded. V3's 3rd Written Warning on the Employee Discipline Form dated 3/17/22 states, Patient's (R2) daughter complained of staff being rude and didn't treat her mother right. Employee stated: Patient didn't like care. I'm not doing any harm to her. I follow protocol before I touch my resident. The Violations checked on this form are Conduct and Performance On 3/25/22 at 1:00 PM V2 stated, With R2, her daughter visits everyday- she called me because she was upset that her mom was woken up really early for a shower, she was startled and scared- so I suspended (V3). We did skin checks and called the doctor. Again, it was poor customer service. On 3/25/22 at 2:00 PM V5 (Assistant Director of Nursing) stated, With (R2) (V3) was upset because she said, I did what I was supposed to do, I didn't do anything wrong. She needed a shower, and I gave her a shower. (V3) was very task oriented. I told her that (R2) was upset, she was frazzled because you scared her. When we heard about this, we called her off of the floor right away and we told her we have to follow protocol and suspend her. 3. On 3/25/22 at 11:00 AM R3 was sitting in a chair in her room. R3 could hear the surveyor talking to R2 through the curtain and requested to speak with surveyor. R3 stated, (V3) was mean. She would come in here and wake us up by yanking back the curtain. She was always yelling and would throw stuff. She didn't belong here, and I hope they don't hire her back. This is a nursing home, not a prison. She was yelling all the time. I was afraid of her, but I would never show it. I think (R2) was very afraid of her. She was not professional at all. She never hit me or called me a name, but she was just mean. R3's Minimum Data Set of 1/7/22 shows that R3 has no cognitive impairment. V3's Final Written Employee Discipline Form dated 3/21/22 states, Employee continues to show poor customer service skills even with peers, residents, and management. (Facility) has decided to terminate. The Violations checked on this form are Conduct, Performance and Work Quality. On 3/25/22 V2 stated, I had to float her from floor to floor- she would fight with other CNAs on 3rd floor, so I floated her to 2nd floor. She started here in 2020 but the past 2 months she didn't get along with new staff, she didn't like change. She thought she shouldn't be moved since she was the permanent staff. After each incident we suspended (V3). We changed her assignments around. (V3) was more upset about us moving her around. (V3) has a loud voice. (R3) didn't like her either. I had to move (V3) away from (R3) also. She would still help with call lights though. Each time we would bring her down to the office to do a write-up, that was our education with her. We would tell her she needs to work on her customer service, and she would say ok. On 3/25/22 at 2:00 PM V5 (Assistant Director of Nursing) stated, When we had to write her up, we did see some improvement with her. We put her on the second floor with the more alert residents. We moved her to the third floor for a while and then back to second. She has been here for several years, and her conduct became so poor over probably the last few months. We decided we just can't have any more complaints about her, so we had to terminate her. She is just a loud person. I tried to tell her that she needed to modulate her voice, so she was not scaring the residents. I told her she was being too loud.

Based on observation, interview, and record review, the facility failed to put an open date on opened medications for two residents (R16 and R35), failed to remove expired medication for 1 resident (R29) and failed to remove debris and loose pills from 2 of 3 Medication carts reviewed for medication storage which can potentially affect all 30 residents on the third floor. Findings include: [DATE] 10:45AM inspected the medication cart on the second floor with V8 (LPN) there was one [MEDICATION NAME] AER-HFA inhaler for R29 with an expiration date of [DATE], an [MEDICATION NAME] nasal spray 0.3% and one [MEDICATION NAME] nasal spray for R35 that were open with no open date and one Mometasome nasal spray for R16 that was open with no open date. [DATE] at 11:00AM, inspected the medication cart on the third floor with V9 (LPN) and there were 29 unidentified loose pills of various shapes and colors, and 8 unidentified half pills of various shapes and colors inside the medication cart. There were also lots of debris and garbage all over the medication cart. When presented with this observation, V9 (LPN) stated that the night shift nurses are supposed to clean the carts and that there should not be loose pills in the medication cart. [DATE] at 2:30PM, interviewed V2 (DON) regarding her expectation for the medication cart and she stated that, the cart should be kept clean and organized, expired and discontinued medications should be returned to pharmacy, all open medications except for house stocks should have an open date, there should be no loose pills in the cart and all nurses are responsible for cleaning the medication cart. Facility policy titled, Storage of Medication (undated), states that it is the policy of the facility to store all drugs and biologicals in a safe, secure and orderly manner. Under procedures, the document states that the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals, all such drugs shall be returned to the dispensing pharmacy. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner.

Based on observation, interview, and record review, the facility failed to complete an individualized and person centered fall risk care plan for one resident (R54) reviewed for falls. R54 was admitted to the facility 09/22/2020. R54's [DIAGNOSES REDACTED]. 10/13/20 12:05 PM R54 yelled help from room. V3 (Receptionist) observed R54 on the floor next to her bed and notified V5 (Registered Nurse). Surveyor observed R54 laying on her back on the floor next to her bed. V5 assessed R54 for injury and asked her what happened .R54 stated she fell out of her wheel chair V5 attended to R54, placed a pillow underneath her head and assessed her pain. R54 stated her pain was mild. V5 asked R54 if she injured any part of her body. R54 stated that she hit her head. V11 (Certified Nursing Assistant) transferred R54 by mechanical lift back to her bed. V5 stated she didn't see any bumps on R54's head but will do a head to toe assessment for bruises and abrasions. V5 stated she will notify the doctor of R54's fall. V7 (Physician) entered R54's room and asked R54 what happened and if she was injured. V7 stated R54 mainly hit her head. V7 assessed R54 for pain and injuries and informed V2 (Director of Nursing) that R54 did not need to be sent out to the hospital. Observed R54. gripping her left shoulder with expressions of pain. R54 stated to V7 that the pain in her shoulder was old and she doesn't believe she hit it. R54 stated to V5 she has pain in both her shoulders. V5 stated she would provide R54 with medicine for her pain and lowered R54's bed to approximately 2ft off floor. R54's fall risk care plan reviewed 10/13/20 documents R54 is at risk for falls related to balance issues, cerebral infarction, hearing and visual impairments with interventions including be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; follow facility fall protocol; evaluate and treat patient as ordered or as needed. R54's Fall risk assessment completed 09/22/20 documents she is a high risk for falls. 10/13/20 01:07 PM V5 (Registered Nurse) stated that R54 had no history of falls and is usually able to transfer herself safely. V5 stated she was not aware of R54 having any previous risks of falls. V5 stated a fall risk assessment will be conducted as a result of her fall. R54's MDS (Minimum Data Set) admission assessment dated [DATE] documents R54 is not steady during transfers and she is only able to stabilize with staff assistance and for transfers between surfaces requires one person extensive assistance. R54's care area assessment dated [DATE] documents a trigger for falls due to balance problems during transition and receiving antidepressant medication and indicated a care plan decision would be needed. 10/14/20 01:12 PM V3 (Assistant Director of Nursing) stated call light positioning is a primary intervention for falls. V3 stated additional preventative fall interventions would include proper foot ware, and interventions put in place include frequent rounding, and bed in low position. V4 (Minimum Data Set Coordinator/Restorative) stated that nursing staff are informed when a resident is high risk for falls. V3 and V4 stated that resident's for fall risks care plans are initially generalized and then updated with specific interventions if a fall incident occurs. V3 and V4 agreed that if R54's care plan had been more personalized it may have prevented her fall on10/13/20. 10/14/20 02:13 PM V2 (Director of Nursing) stated that nurses conduct admission assessments. V2 stated that interventions such as placing a resident closer to the nurses station, increased monitoring, ensuring the environment is cleared of debris, reorienting the resident to the facility when indicated, and ensuring resident receives toileting assistance are included in a fall risk care plan. V2 stated that upon admission nurses should initiate a detailed care plan based on their initial assessment of a resident. V2 stated that care plans are updated to include root cause analysis after a fall incident. V2 stated that care plan interventions should be implemented by nurses upon admission. V2 stated that within 3 days of completing an initial admission care plan restorative conducts a detailed assessment of residents and revises the care plan as needed. V2 stated that R54's current fall risk care plan was not sufficient and should have included additional detailed and personalized interventions. V2 stated that transfers should have also been added to R54's activities of daily living care plan. V2 stated that R54's fall risk care plan was too generalized.

Based on interview and record review, the facility failed to notify a Power of Attorney regarding a significant change in behavior which required hospitalization ; and failed to ensure that staff followed their facility policy regarding notification of changes, which affected one resident (R1) of three residents reviewed for notification of changes in a sample of three. Findings include: R1's Admission Record documents the following medical Diagnoses: [REDACTED]. V8 (POA-Power of Attorney) is listed as R1's POA over Healthcare since (MONTH) 26, 2009. On 3/18/19, it is documented that R1 became aggressive with staff, striking with a cane. This behavior continued on 3/20/19 at 8:30am with an episode of R1 striking another staff member with a cane. Another episode of a staff member being struck by R1's cane was documented at 8:55am on 3/20/19. V8 was not notified of R1's aggressions or significant change in behaviors. From 2/1/19 through 3/18/19, there was no documentation of this type of physical aggression. On 3/20/19 at 12:00pm, V7 (Physician) was notified regarding R1's behavioral issues and ordered to send R1 to the emergency room for evaluation and treatment related to an increase in physically aggressive behaviors. At 2:00pm, the ambulance arrived for transport. V8 was not notified of R1's significant change in behavior related to an increase in physically aggressive behaviors until 3/20/19 at 2:27pm. This was after R1 was taken to the hospital by ambulance. The facility schedule documents that V5 (LPN-Licensed Practical Nurse) was the nurse scheduled and in charge of R1's care on the 3rd floor on 3/20/19, the day that R1 was sent to the hospital. On 12/24/19 at 11:32am, V5 indicated that she did not recall if she was the nurse that sent R1 out to the hospital on [DATE]. V5 stated, Our protocol is to always notify the POA first if a resident gets sent out. V5 also stated, If there's a significant change in behavior, we definitely call the POA to let them know. On 12/26/19 at 11:50am, V12 (Social Service Director) stated, Around the time of the psychiatric episode, (R1) had many med(ication) refusals. But calling (V8) helped. (R1) was suspicious of nurses. V12 indicated that R1's striking at people was out of the ordinary for him and was definitely a change in behavior. A facility policy dated (MONTH) (YEAR) and titled, Change in Resident's Condition or Status documents: Policy: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. Procedure: 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: b. There is a significant change in the resident's physical, mental, or psychosocial status; e. It is necessary to transfer the resident to a hospital/treatment center.

Based on observation, interview and record review, the facility failed to provide incontinence care in a manner that would improve hygiene and prevent the potential spread of infection. This applies to 1 of 3 residents (R20) reviewed for incontinence care in the sample of 13, and 3 residents (R12, R19, and R31) in the supplemental sample. The findings include: 1. Face sheet, dated 3/12/19, shows R12 has [DIAGNOSES REDACTED]. MDS (minimum data set) assessment dated [DATE] showed that R12 has severely impaired cognition, requiring extensive assistance in transfer, bed mobility, toilet use, bed mobility, and bathing. On 03/12/19 at 09:35 AM, R12 was up in wheelchair. V10 (CNA, certified nursing assistant) and V11 (CNA) took R12 to her room. V10 and V11 donned gloves. R12 was transferred from the wheelchair to the toilet with the use of mechanical lift. V10 and V11 unfastened R12's incontinence brief then V11 removed R12's incontinence brief. The incontinence brief was soaked with large amount of loose stool. V11 wiped R12's rectal area and transferred R12 to the toilet. R12 had bowel movement in the toilet. V10 took a disposable wipe and wiped R12's front area and rectal area while R12 was standing on the mechanical lift. Both CNAs did not clean R12's buttocks and thighs nor separated the labia. 2. Face sheet, dated 3/12/19, shows R20 has [DIAGNOSES REDACTED]. MDS (minimum data set) assessment dated [DATE] showed that R20 has severely impaired cognition. R20 also requiring extensive assistance of one staff member with bed mobility, transfer, dressing, toilet use, personal, hygiene and bathing. On 03/12/19 at 12:35 PM, V10 transferred R20 from the wheelchair to the toilet ,with the use of gait belt. The incontinence brief was saturated with urine. R20 urinated again in the toilet. While R20 was standing in the bathroom holding onto the grab bar on the wall, V10 wiped R20's rectal area with disposable wipes. V10 pulled up R20's incontinence brief and pants then assisted R20 back to the wheelchair. V10 did not wipe R20's buttocks and front perineal area. 3. On 03/12/19 at 1:35 PM, V8 (Staffing coordinator/CNA) took R19 to the washroom to perform incontinence care. V8 removed R19's soiled incontinence brief. V8 assisted R19 to the toilet seat. R19 had very loose stools. While R19 was holding on to the grab bar ,V8 ,CNA. cleaned R19's rectal area, V8 failed to clean R19's penis and scrotum. On 3/12/19 at 2:10 PM, V8 stated cleaning R19 was not easy in the bathroom. Review of R19's electronic health record (EHR) showed R19 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R19's minimum data set ((MDS) dated [DATE] showed R19 requires extensive assistance of one to two staff members for bed mobility, transfer, dressing, toilet use, and personal hygiene. R19's EHR showed R19 is always incontinent of urine and frequently incontinent of stool. 4. On 03/12/19 at 1:15 PM, V7 (CNA) was performing incontinence care on R31. R31 was lying in bed, V7 turned R31 to her left side. V7 removed R31's incontinence brief. V7 took the washcloth and cleaned R31's perineal area without separating R31's labia. R31's EHR electronic health record showed R31 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R31's minimum data set ((MDS) dated [DATE] showed R31 requires extensive assistance of one to two staff members for bed mobility, transfer, dressing, toilet use, and personal hygiene. The MDS also showed R31 is always incontinent of bowel and urine. On 3/13/19 at 2:30 PM, V2 (Director of nursing, DON) stated nursing staff should clean female residents by opening the labia and for male residents they should wash the perineal area including the penis and scrotum as per facility's policy. The facility's policy and procedure for perineal care with revision date (MONTH) (YEAR) showed: Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Procedure for a female resident: a. Wash perineal area, wiping from front to back b. Separate labia and wash area downward from front to back accounting to wash perineum d. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. For a male resident: a. Wash perineal area starting with urethra and working outward. protract foreskin of the uncircumcised male. accounting to wash the perineal area including the penis and scrotum. d. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks.

Based on observation, interview, and record review the facility failed to follow standards of infection control practices with regards to hand washing and changing gloves during provisions of care. This applies to 1 of 1 residents (R20) reviewed for infection control in the sample of 13, and 3 residents (R12, R19, and R31) in the supplemental sample. The findings include: 1. Face sheet, dated 3/12/19, shows R12 has [DIAGNOSES REDACTED]. MDS (minimum data set) assessment dated [DATE] showed that R12 has severe impairment cognitive, requiring extensive assistance in transfer, bed mobility, toilet use, bed mobility, and bathing. On 03/12/19 at 09:35 AM, V10 and V11 (both CNAs, certified nursing assistant) provided incontinence care. R12 was incontinent of large amount of loose stool. After completing the incontinence care, V10 and V11 left R12's room without hand washing. 2. Face sheet, dated 3/12/19, shows R20 has [DIAGNOSES REDACTED]. MDS (minimum data set) assessment dated [DATE] showed that R20 has severely impaired cognition. R20 also requires extensive assistance of one staff member for bed mobility, transfer, dressing, toilet use, personal, hygiene and bathing. On 03/12/19 at 12:35 PM, V10 provided incontinence care to R20. After the incontinence care ,V10 removed her gloves and left the room without hand washing. 3. On 03/12/19 at 1:35 PM, V8, Staffing coordinator/CNA, removed R19's soiled incontinence brief,changed her gloves, but failed to perform hand hygiene. R19 had very large, watery stool. V8 cleaned R19's buttocks area, removed her gloves twice in the process of cleaning R19 without performing hand hygiene. Review of R19's electronic health record (EHR) showed R19 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R19's minimum data set ((MDS) dated [DATE] showed R19 requires extensive assistance of one to two staff members for bed mobility, transfer, dressing, toilet use, and personal hygiene. R19's EHR showed R19 is always incontinent of urine and frequently incontinent of stool. 4. On 03/12/19 01:15 PM V7 (CNA, Certified Nursing Assistant) was performing incontinence care for R31. V7 removed R31's incontinence brief, failed to remove gloves or washed hands after handling soiled brief. V7 used the same set of gloves throughout the incontinence care for R31. R31's EHR electronic health record showed R31 was originally admitted to the facility 11/20/18 with [DIAGNOSES REDACTED]. R31's minimum data set ((MDS) dated [DATE] showed R31 requires extensive assistance of one to two staff members for bed mobility, transfer, dressing, toilet use, and personal hygiene. The MDS also showed R31's always incontinence of bowel and urine. On 3/13/19 at 2:30 PM, V2 Director of nursing (DON) stated nursing staff should perform hand hygiene after removing gloves. The facility's policy and procedure for hand washing/hand hygiene with revision date (MONTH) (YEAR) showed: Policy: The facility considers hand hygiene the primary means to prevent the spread of infections. Procedure: Use an alcohol based hand rub or alternately, soap and water for the following situations: a. Before and after direct contact with residents. b. After contact with a resident's intact skin. c. After contact with blood and bodily fluids. d. After removing gloves. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing health care associated infections.

Based on interview and record review, the facility failed to provide ABNs (Advanced Beneficiary Notices) to residents transferring payor sources from Medicare A to custodial care within the facility. This applies to 1 of 1 resident (R33) reviewed for ABNs (Advanced Beneficiary Notice) in a sample of 13, and 2 residents (R22 and R29) in the supplemental sample. The Findings include: NOMN[NAME] (Notice of Medicare Non-Coverage, dated 1/11/19, shows R33's skilled nursing/therapy services ended on 1/16/19. NOMN[NAME], dated 8/10/18, shows R29's skilled nursing/therapy services ended on 8/13/18. NOMN[NAME], dated on 3/8/18, shows R22's skilled nursing/therapy services ended on 3/16/18. The clinical records show R33, R29 and R22 all remained in the facility after skilled nursing/therapy services ended. The facility was unable to provide documentation that R33, R29 and R22 received ABNs (Advance Beneficiary Notices) when they transferred from Medicare A services and to custodial care within the facility. On 03/12/19 at 11:43 AM, V1 (Administrator) stated all three residents remained in the facility after their Medicare A benefits ended, however they had not exhausted their 100 total days of Medicare A benefit. V1 stated he misunderstood and thought that he only had to provide ABN forms to residents who utilized their entire 100 Medicare A days and then transferred to custodial care within the facility. Facility Procedure Medicare Advance Beneficiary Notice, dated (MONTH) (YEAR), stated the policy is to ensure that an appropriate Advance Beneficiary Notice (ABN) is obtained from Medicare beneficiaries services that are not paid by Medicare because they are deemed to be not reasonable and necessary.

Based on observation, interview and record review, the facility failed to administer medications per physician orders. There were 25 opportunities with 2 errors which resulted in 8% medication error rate. This applies to 2 of 5 resident (R15 and R247) observed during medication administration. The Findings include: On 3/11/19 at 5:00 PM, V4 (Licensed Practical Nurse) administered Humalog Insulin 8 units (2 units scheduled dose and 6 units per sliding scale) subcutaneously on R15's right arm using the Kwikpen to R15. V4 did not prime the insulin needle by turning the dose selector to remove the air to ensure that R15 received the full dose of 8 units of Insulin On 3/12/19 at 12:13 PM, V2 (Director of Nursing) said she expected the nursing staff to prime the insulin needle by turning the dose selector to 2 units after connecting the needle to the cartridge, hold the pen upright and press the pen button all the way. V2 stated that after a drop of insulin appear at the tip of the needle, then the needle is primed. This ensures that there are no air bubbles and the resident gets the full dose of the required insulin amount. The facility policy titled, Insulin Pen Injection Administration, dated (MONTH) (YEAR), required, Procedure: 8. To prime, turn the dose selector to 2 units. Hold pen with the needle pointing up and tap the cartridge gently to move air bubbles to the top. Press the button all the way in a drop of insulin should appear at the tip of the needle. The manufacturer safe injection guide for KwikPen showed: Prime before injection 6. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime the KwikPen before each injection, the patient may get too much or too little insulin. 2) On 3/12/19 at 8:32 AM, V5 (Registered Nurse) administered oral medications to R247 as follow: [MEDICATION NAME] 5 mg (milligram) PO (oral), Aspirin chew 81 mg PO (HS-house stock), [MEDICATION NAME] 0.0625 mg= 1/2 tab PO, [MEDICATION NAME] 240 mg PO, [MEDICATION NAME] 25 mg PO, Risaquad 1 cap PO, Spirinolactone 1/2 tab=12.5 mg PO, [MEDICATION NAME] 20 mg PO. During medication reconciliation, R247's (MONTH) 2019 POS (physician order [REDACTED]. On 3/13/19 at 11:30 AM, V9 (pharmacist) said that the physician ordered [MEDICATION NAME] 325 mg PO daily and not [MEDICATION NAME].

Based on observation, interview and record review, the facility failed to follow facility's policy and procedure and manufacturer's guideline regarding insulin administration. This applies to 1 of 5 resident (R15) observed during medication administration. The Findings include: On 3/11/19 at 5:00 PM, V4 (Licensed Practical Nurse) administered Humalog Insulin 8 units (2 units scheduled dose and 6 units per sliding scale) subcutaneously on R15's right arm using the Kwikpen to R15. V4 did not prime the insulin needle by turning the dose selector to remove the air to ensure that R15 received the full dose of 8 units of Insulin On 3/12/19 at 12:13 PM, V2 (Director of Nursing) said she expected the nursing staff to prime the insulin needle by turning the dose selector to 2 units after connecting the needle to the cartridge, hold the pen upright and press the pen button all the way. V2 stated that after a drop of insulin appear at the tip of the needle, then the needle is primed. This ensures that there are no air bubbles and the resident gets the full dose of the required insulin amount. The facility policy titled, Insulin Pen Injection Administration, dated (MONTH) (YEAR), required, Procedure: 8. To prime, turn the dose selector to 2 units. Hold pen with the needle pointing up and tap the cartridge gently to move air bubbles to the top. Press the button all the way in a drop of insulin should appear at the tip of the needle. The manufacturer safe injection guide for KwikPen showed: Prime before injection . 6. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime the KwikPen before each injection, the patient may get too much or too little insulin.

Based on observation, interview and record review, the facility failed to ensure the cooking equipment is clean and freezer is free of frost. The facility also failed to ensure food is served in a sanitary manner. The failures affect all 55 residents receiving oral diets from the facility's kitchen. Findings include: Citadel of Wilmette Client Info dated 4/24/18 indicating a total of 55 residents receiving oral diets. On 4/24/18 at 10:20am, this writer noted heavy grease and dirt built-up in two ovens under the stove top. V3 (Dietary Manager) stated The ovens could use a little freshen up, they are supposed to be cleaned weekly. We don't have a cleaning record for it. On 4/24/18 at 10:25am, this writer noted heavy frost built-up in an upright freezer where foods are stored. V3 stated, the freezer should be defrosted weekly. On 4/24/18 at 12:05pm during lunch tray line observation, this writer noted V3 (Cook)'s sleeves visibly soiled, the soiled sleeves touching the clean dishes and the cooked foods in the steam table while serving lunch. On 4/24/18 at 12:40pm, V3 stated, the cook needed to pull up his sleeves to prevent touching the foods and the clean dishes to avoid cross contamination. Employment Practices dated (YEAR) reads, Each employee is expected to wear a clean uniform every day Holding and Service dated (YEAR) reads, Service: Dishes and utensils are handled in a way which does not contaminate the surface the food touches. Care is taken to observe the following steps: Avoid touching the eating surface of the dish or bowl

Based on record review and interview, the facility failed to ensure that proper technique and safety measures were used during incontinence care for 1 of 3 residents(R1), reviewed for falls. These failures resulted in R1 sustaining a fractured arm. Findings include: Incident report dated 4/10/13 at 2:00AM indicates that R1 fell to the floor, from bed, while receiving incontinence care by E5(Certified Nursing Assistant). Resident complained of excruciating pain and was unable to move the left arm. Resident was transferred to the hospital for an evaluation. On 4/10/13, R1 returned to the facility with a [DIAGNOSES REDACTED]. Careplan review indicates that R1 is at risk for falls and requires total assist with all ADLs (Activities of Daily Living). Review of the facilities incident investigation dated 4/10/13 includes an interview of E5. Per interview dated 4/11/13, E5 stated the following," At 2am, I started my rounds for the incontinence care, when I got to resident's room, resident was asleep. I woke her up and I told her I have to change her incontinent brief, resident stated," yes" . Resident was alert and fully awake when she replied. The resident was in the middle of the bed, so I moved resident more towards me before I turned her on the right side, the resident was not turned enough so I told her to turn more on the right side a little bit, I started removing her soiled incontinent brief. I was bent down a little bit because her bed was in low position, she is usually an easy one because she helps with the incontinent brief changes so I didn't raise the bed up. When I lifted myself up to reach the clean incontinent brief from the head of the bed, the resident rolled off from the bed; it happened so fast that I was not able to catch the resident, then I called for help." On 4/17/13 at 4:15pm E3 Registered Nurse (RN) stated " I was the RN on call. (E4, RN) called me at 7:20am about (R1's) incident. (R1) went out and came back with a sling in her arm. (E5) were changing (R1) and (R1) slid out of bed, bed was low. (E5) was providing incontinence care; the incontinent brief was by the head of the bed. (E5) went to grab it and (R1) rolled out of bed. (E5) was surprised that (R1) rolled out of bed." On 4/22/13 at 8:15am E5, CNA stated " I never had any incidents with residents before. I turned R1 towards the window and I was behind her. R1 elevated her left leg and went to the floor. R1 fell on her left shoulder. The incontinent brief I was going to grab was at the head of the bed. No I didn't leave the bedside. It was like magic, in a twinkle of an eye she fell ." Facilities fall policy indicates that fall prevention interventions are to be implemented at all times. Facility Incontinence Care Policy updated on 12/12 documents under: Procedure: 7. " Assist to side lying position by turning towards caregiver, unless more than one caregiver present. If more than one caregiver present, one caregiver provides support of patient to maintain side lying position while the other caregiver completes the procedure. "